A Case Study of Building Strong Brains Tennessee: National ...
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A Case Study of
Building Strong
Brains Tennessee:
An Initiative to Address
Adverse Childhood
Experiences and
Become a Trauma-
Informed State
MARCH 2021
Executive Summary
A dverse childhood experiences (ACEs) can have a significant impact on a persons’ life, including on their health
and well-being into adulthood. Interest in preventing and addressing the consequences of ACEs has grown
across sectors and is shaping policy discussions among state and local leaders who are eager to build capacity
to support effective prevention and intervention. Building Strong Brains Tennessee (BSBTN) is a public/private
partnership established to prevent and mitigate the impacts of ACEs for all Tennesseans and to promote statewide
economic development and prosperity. BSBTN is jointly led by the executive, legislative, and judicial branches of state
government and mobilizes knowledge derived from the science of brain development and communication science.
The National Governors Association Center for Best Practices (NGA Center), in partnership with the Duke-Margolis
Center for Health Policy (Duke-Margolis), have established a 5-state learning collaborative on ACEs. In this case
study, NGA Center, Duke-Margolis and a former Tennessee leader highlight BSBTN and its key elements of success
as one model from which other states can learn. Success of the initiative can be attributed to the widespread
commitment to address, prevent, and educate throughout the state about the long-term impact of ACEs. The
following factors are critical to the success of BSBTN:
} Champions across the three branches of government, among foundations and within the community. Strong
leaders at every level embedded the mission of BSBTN in public remarks, policy discussions and in the community.
} Public/Private Collaboration. The public/private relationships that serve as the foundation for BSBTN’s structure
has assured local solutions are being developed to address community issues.
} Empowering Communities to Act. Communities—fundamental to the success of BSBTN—were prepared and
supported by the three branches to act and innovate.
} Focus on Creating Culture Change. Transforming thinking and actions across all functions of society led to culture
change, emphasizing making changes in an individual or groups’ own sphere of influence.
} Evidence-Informed Messaging. Extensive use of research-tested terminology and methods of communication
permitted common understandings of the mission and expectations for culture change. BSBTN also periodically
assessed what works and refined their approach knowing culture change is not a sprint but a marathon.
} Sustainable Resources. Financial, in kind, and programmatic supports across government and from key partners
helped get the initiative off the ground and maintain ongoing work. Approaches to assure sustainability both with
and without dedicated fiscal resources were critical to facilitating future work.Introduction
A dverse childhood experiences (ACEs), such as physical and emotional abuse or neglect, or domestic violence,
can have a significant and sustained impact on a person’s life expectancy and overall health and well-
being.1 A milestone 1995 study conducted by the Centers for Disease Control and Prevention (CDC) and Kaiser
Permanente found a strong correlation between a high number of ACEs and increased likelihood of poor health
outcomes as an adult, as well as having a negative impact on academic achievement, time away from work, and
early death.2 CDC estimates that “61% of adults had at least one ACE and 16% had 4 or more ACEs.”3
Interest in preventing and addressing the consequences of ACEs has grown across sectors. That interest is
increasingly shaping policy discussions among state and local leaders who are eager to build capacity to support
effective prevention and intervention. This interest in ACEs, alongside state work on addressing the needs of
the whole family through multi-generation approaches and state implementation of the Family First Prevention
Services Act, has increased interest in social emotional learning and trauma-informed schools. Action to address
families impacted by the opioid crisis is also building a groundswell of support to move state policy, programming,
and funding toward concrete solutions.
The long-term impact of ACEs and trauma on health and behavior is an issue gaining increasing recognition
among state policymakers. The National Governors Association Center for Best Practices, in partnership with the
Duke-Margolis Center for Health Policy and a former leader in Tennessee’s strategic implementation of Building
Strong Brains Tennessee, are currently working with five states — Delaware, Maryland, Pennsylvania, Virginia,
and Wyoming — to develop sustainable state-level strategies to prevent and mitigate childhood traumas
associated with ACEs. The project features Building Strong Brains Tennessee (originally known as the Building
Strong Brains Initiative) as a leading example of a statewide intervention to achieve a sustained culture change
through implementing a philosophy, policies, programs, and practices aimed at preventing ACEs and changing the
course of childhood trauma.
Building Strong Brains Tennessee (BSBTN) is a public/private partnership that was established to prevent and
mitigate the impacts of ACEs for all Tennesseans and to promote statewide economic development and prosperity.
BSBTN is jointly led by the executive, legislative, and judicial branches of state government and mobilizes
knowledge derived from the science of brain development and communication science, often referred to by
Tennessee as a three-branch, two-science approach. BSBTN sought to achieve culture change across all sectors
and across all levels of government and community, emphasizing the importance of taking ownership over an
individuals or groups own sphere of influence (Figure 1). The initiative was built upon a three-pronged philosophy:
} Investments in childhood can produce long-term improvements in the cognitive and social development of
children. This investment is important to building healthy, strong future generations and citizens.
} B
SBTN’s goal is to make sure all Tennessee children have what they need to thrive.
} U
nderstanding how the future prosperity of Tennessee depends on building strong brain architecture in early
years has crystalized in a way that makes it imperative to act.4
BSBTN introduced the Brain Architecture analogy to the public, which explains the idea that the basic
architecture of the human brain is constructed through an ongoing process that begins before birth and
continues into adulthood. Like the construction of a home, the building process begins with laying the foundation,
framing the rooms and wiring the electrical system in a predictable sequence. Early experiences shape how
the brain is built, establishing either a sturdy or a fragile foundation for the development and behavior that
follows, and establishing a strong foundation early on is easier than addressing issues later in life. This metaphor
articulates values important to Tennesseans, including future prosperity and success, described effects of trauma
and roles of communities in building resilience, and includes a call for change in the culture. It provides common
language stakeholders can use when communicating about ACEs, trauma, and healthy social/emotional and
physical development.
2 A Case Study of Building Strong Brains Tennessee: An Initiative to Address Adverse Childhood Experiences and Become a Trauma-Informed StateFigure 1: BSBTN Elements of Culture Change
PREVENTION, MITIGATION AND TREATMENT OF ADVERSE CHILDHOOD EXPERIENCES
ANTICIPATED MULTI-SECTOR, MULTI-LEVEL PUBLIC AND PRIVATE IMPACTS
Adult Justice
& Corrections ² Faith-Based
Communities
²
²
Higher
PROFESSIONAL Education &
Philanthropy PRACTICE Academia
²
²
PROGRAMS
AND SERVICES Education &
Early Care
Business &
Coporations
²
POLICIES
²
AND FUNDING
Child Welfare
& Juvenile
Community Justice
PHILOSOPHY
²
²
AND
APPROACH
Mental Health
Media
& Substance
² Abuse Services
²
Human
Services ² Health Care Services
& Financing
Figure 1 demonstrates the framework BSBTN’s coordinating team developed, which recognizes all stakeholders’ and
sectors’ capacities for strategic transformation within their own spheres of influence. BSBTN sought to achieve culture
change through transformation in prevention, mitigation, and treatment of ACEs at four levels, referred to as “the 4Ps.”
Governance and Infrastructure
C ritical to the success of BSBTN is a strong governance and infrastructure model that relies on all three
branches of government, as well as key stakeholders in the community. The three branches institute (now
dormant), a public and a private-sector steering group, and a small coordinating team helped to guide the
collective efforts of BSBTN in the state (Figure 2). The steering groups met individually and jointly, emphasizing
how public/ private partnerships are foundational to BSBTN.
A Case Study of Building Strong Brains Tennessee: An Initiative to Address Adverse Childhood Experiences and Become a Trauma-Informed State 3Figure 2: BSBTN’s Governance Structure
Three Branches Public Sector Private Sector Coordinating
Group
Institute Steering Group Steering Group Team
Membership Executive branch Comprised of Comprised of Comprised of
child-serving ranking staff of providers, trade ranking staff of
departments— the Departments associations, the Departments
Children Services, of Children’s community of Children’s
Health, Education, Services, organizations, Services, Health,
Human Services, Education, Health, advocates, Education,
Mental Health Human Services, foundations, Human Services,
& Substance Intellectual & policy researchers, and Tennessee
Abuse—plus Developmental medical society, Commission on
Children’s Cabinet, Disabilities, hospitals, chamber Children and
Commission on Mental Health & of commerce, and Youth, plus three
Children and Substance Abuse, clergy representatives of
Youth, TennCare Office of Criminal the private sector
plus Labor and Justice Programs, (two of whom co-
Workforce Commission on chair the Private
Development, Children & Youth, Sector Steering
Department of and University Group) and two
Corrections, of TN Extension foundations
TN Bureau of Services
Investigation, and
Administrative
Office of the
Courts
Function The oversight Guides state Serve as extenders Provides overall
body to which efforts to of BSBTN’s guidance, input,
BSBTN is held implement mission and as and administrative
accountable, has state-level policy implementers of oversight of
to gain consensus and program ACEs-informed BSBTN. Relies on
from on priorities, approaches to strategies within input from the
and which has to prevent and their organizations, Steering Groups to
approve activities mitigate ACEs, regions, and local share knowledge
and use of funds coordinate communities
interagency ACEs-
related activities,
and build on work
already occurring
in state agencies
Engagement Collective impact. Consensus Consensus Meets weekly to
Model Met quarterly model. Convenes model. Convenes set a course of
2011-2019, now individually and individually and action
dormant jointly with the jointly with the
Private Sector Public Sector
Steering Group on Steering Group on
a quarterly basis a quarterly basis
4 A Case Study of Building Strong Brains Tennessee: An Initiative to Address Adverse Childhood Experiences and Become a Trauma-Informed StateThe executive, legislative, and judicial branches provided strong in-kind as well as programmatic and policy support
for the three branches institute and for BSBTN (Figure 3).
Figure 3: Three Branches and Foundation Commitment
Executive Branch Legislative Branch
• T he Governor, first lady, and deputy governor provided extensive • N umerous legislative hearings focused on BSBTN, ACEs,
public support. and trauma.
• In fiscal year 2020, BSBTN allocated a portion of its funding to 15 • Legislative appropriations aligned with the governor’s proposal
of the state’s 95 counties identified as “Economically Distressed” to dedicate resources for “ACEs-related activities” annually
to address unique local concerns about children’s welfare and in in FY17 and FY18, and on a recurring basis beginning with FY19.
support of the governor’s first Executive Order. The appropriations assured funding for Community Innovations
• The state made a second allocation of BSBTN resources in spring grants.
2020 to support families and caretakers due to the financial • Legislators participated in regional convenings to increase
impact of COVID-19 in the 15 economically distressed counties. education and public awareness.
• State employees’ time was provided to the initiative by way of in-kind • Examples of four laws enacted since 2017 that focus on different
resources and policy support for governance bodies, management of elements of ACEs include:
key grants, training activities, materials, logistics and planning. – Tennessee Zero to Three Court Initiative
• Several state agencies adopted trauma-informed policies and (TCA ξ 37-1-901) establishes Safe Baby
practices. Courts;
• The state appropriated Community Innovations – Development of training programs for
grants, administered through the Department of ACEs in the Department of Education
Children’s Services, beginning in 2016 to support (TCA ξ 49-1-230)
communities in implementing ACEs-related – Trauma-Informed discipline policies in
activities statewide. The Community schools (TCA ξ 49-6-4109)
Innovations projects have made significant
contributions toward the prevention and – Requirement for ACEs training for parents
mitigation of ACEs throughout Tennessee divorcing (TCA ξ 36-6-710)
and have advanced specific trauma-
informed efforts in their respective fields THREE BRANCHES
beyond Tennessee.
AND FOUNDATION
COMMITMENT
• T ennessee Supreme Court justices • F
oundations were critical to the
participated in the kick-off summit at development and implementations of
which the Chief Justice spoke. BSBTN. Foundations participated as part
• With in-kind assistance from the of the core BSBTN Coordinating team,i
Administrative Office of the Courts, all • Provided critical support for the framing
juvenile court judges in the state as well symposia discussed in the next section;ii
as their magistrates and staff received • Funded an evaluation of BSBTN;iii and
BSBTN training, a tremendous break-through
in expanding application of the two sciences to • Supported the knowledge mobilization faculty, as
an integral component of Tennessee’s systems. There described in more detail on following page.iv
is increasing emphasis on knowing how experiences of juvenile
justice youth might have contributed to behavior resulting in his/
her appearing before the court. Foundation Support ~
• The courts have developed policies and practices to advance
healthy environments for the youngest vulnerable Tennesseans. i Sponsored by Casey Family Programs
ii Sponsored by the ACEs Awareness Foundation
iii Sponsored by the ACEs Awareness Foundation and completed by the University of Tennessee
Judicial Branch ~ College Office of Social Work Office of Research & Public Service
iv Sponsored by The Health Trust
1. 2. 3. 4. 5. 6. 7.
Department Department Department Department of Department of Department Office of Criminal
of Children’s of Education of Health Human Services Mental Health of Corrections Justice Programs
Services included a Whole included ACEs in policies required & Substance established funded public
incorporated Child approach, conversations and childcare Abuse Services “The Children’s awareness campaigns
BSBTN principles to serve the in assessments educators in incorporated Gallery,” a and provided for
into foster academic and as part of the center, group, and BSBTN into the home-like setting implementation of
parent training; non-academic Community family settings federally-funded in a women’s “Handle with Care”
needs of all kids, Health Councils to periodically go System of Care rehabilitation statewide to build
as one of their and prioritized through trauma- Across Tennessee center to partnerships between
four top priorities; ACEs as part of informed trainings; program, which allow eligible schools, corrections,
the department’s aims to ensure incarcerated and the community
strategic plan, access to women weekend and to ensure
developing an coordinated visits with their that children who
ACEs charter; community- children in age- experience trauma
based services appropriate pods; and interact with
for behavioral police outside of
health across the school are handled
lifespan; with care while in
school.
A Case Study of Building Strong Brains Tennessee: An Initiative to Address Adverse Childhood Experiences and Become a Trauma-Informed State 5Turning Knowledge into Action
B SBTN engaged in what came to be known as knowledge
mobilization to implement the idea that knowledge must be
put into action within one’s respective environments and roles.
AN EARLY PRIORITY FOR BSBTN WAS THE
USE OF EVIDENCE-BASED COMMUNICATION
The Building Strong Brains Initiative kick off Summit focused
on exposure to the two sciences and was attended by state and TO CREATE A COMMON LANGUAGE AND
local government officials, community leaders, legislators, judges,
A COMMON LENS THROUGH WHICH TO
philanthropists, educators, academics, professionals, trade
organizations, clergy, and media. An early priority for BSBTN was DISCUSS AND VIEW CHILD DEVELOPMENT.
the use of evidence-based communication to create a common
language and a common lens through which to discuss and view
child development. This first influential step created an understanding of the potential harmful effects of trauma
on brain development. The next step was the widespread adoption of the two-sciences approach to addressing,
preventing, and mitigating ACEs, building resilience, and being trauma informed.
Seminal components of the knowledge mobilization path included building scientific and policy understanding
through three scientific symposia, learning how to apply communications to brain science through four
convenings hosted by the FrameWorks Institute, widespread training, and subsequently building and sustaining
grassroots momentum through localized knowledge mobilization teams.
Build Scientific and Policy Understanding
BSBTN hosted three scientific symposia focused on the science of biology/physical science, programmatic
innovations; and policy innovations (see recordings from Symposium 2 here). Experts from across the U.S. and
Canada shared information on topics that informed Tennessee’s direction and actions. The sequence of applying
communication science in each of the symposia strengthened the case for using a common language.
Learn How to Apply Communication to Brain Science
BSBTN partnered with the FrameWorks Institute, an interdisciplinary team of social scientists, linguists, and
communications practitioners who work with advocates, policy makers, funders, and others to frame complicated
social and scientific issues in understandable, actionable terms. In collaboration with this group, BSBTN and
FrameWorks hosted four convenings of individuals from all sectors and professional disciplines to learn how
to apply communication tools to brain science to understand why it is important to invest in early childhood,
youth, and young adults. After intensive, interactive training, participants practiced for about a month using the
structure of the story arc for all relevant communications within their respective spheres. The story arc structure
consists of values and metaphors to describe the topic and problem, and a description of the solution. After this
period, the group reconvened to learn about infant mental health and practice framing information for social
media communications.
Implement Widespread Training
Creating public awareness of the impact of ACEs has been a major goal of BSBTN since the program’s inception.
Training has been essential in making sure this information is shared statewide and at the grassroots level. Three
principal strategies have been deployed to train across the state.
Train the Trainer: Using materials developed in conjunction with the Harvard Center for the Developing Child
and with leadership from the Tennessee Commission on Children and Youth, individuals from diverse professional
disciplines and sectors were trained on brain development, trauma-responsiveness, ACEs prevention, mitigation,
and skill building for the public. According to state records, over 1,180 trainers have trained over 80,000 people
statewide. To achieve fidelity to the model and to continually improve quality, the Tennessee Commission
on Children and Youth has established a virtual learning collaborative that serves as a platform for trained
individuals to request and share information and resources, as well as track trainings provided.
Training Educators and Administrators: The Department of Education trained over 7,000 educators and
administrators during the first two years of the program (roughly 7.5% of all educators in the state). Due to
widespread interest, the model was restructured to develop in-school expertise. As a result, 71 of the 150+
6 A Case Study of Building Strong Brains Tennessee: An Initiative to Address Adverse Childhood Experiences and Become a Trauma-Informed Stateschools that applied were selected and became certified as trauma-informed schools. Completion of that
curriculum meant the school had the capacity to train all staff, including support staff, in how best to interact
with and respond to students in constructive ways. The model was enhanced to engage entire school systems in
trauma training in support of the CDC Whole School, Whole Community, Whole Child Model.
Public Awareness: BSBTN and the Office of Criminal Justice Programs combined resources to fund a six-episode
series on public television, Building Strong Brains—The Tennessee Story, that was made available to all public
television stations in the state. Eight brief educational segments and four public service announcements were
created from the original series.
Beginning in spring of 2019, the Tennessee Commission on Children and Youth spearheaded a social media
campaign to extend the reach of public awareness efforts with support from FrameWorks (recent posts
can be found on social media with the #BSBTN hashtag). Leveraging existing networks with thousands of
representatives, the campaign sought to engage the community at large, provide opportunities to disseminate
information, and support the creation of a trauma-informed culture in the state.
Build and Sustain Grassroots Momentum
Knowledge Mobilization Teams throughout the state (facilitated by Regional Coordinators of the Tennessee
Commission on Children and Youth) enact strategies to address ACEs and build upon local insights, assets,
and challenges to build community awareness and action. Regional Coordinators convene cross agency
collaborations; familiarize local leaders w/ ACEs-related activities; provide information to local media; and make
presentations and public awareness materials broadly available. The approach has contributed to continued
grassroots support for BSBTN’s mission as COVID-19 has limited the resources available for direct interaction.
During the first three years of BSBTN, the Department of Children’s Services competitively awarded 35 Community
Innovation grants. The grants reflect an interdisciplinary effort informed by the BSBTN Coordinating Team.
Applicants had to provide evidence of a deep understanding of the two sciences, demonstrate their proposal was
appropriate for the community or venue, use an evidence-based or promising practice or have a strong theory of
change, and address equity, inclusion, and other indicators of cultural competence. Since the first year, priorities
for proposals have remained true to the initial requirements, yet have evolved alongside contemporary issues and
the capacities of communities, priorities of the administration, and the availability of funding.
Conclusion
Interest in preventing and addressing the consequences of ACEs has burgeoned across health, behavioral health,
education, and human service sectors. That interest is increasingly shaping policy discussions among state and
local leaders eager to build capacity to support effective prevention and intervention. This interest in ACEs has
created an opportune moment to move state policy, program, and funding approaches toward real solutions—
especially when combined with state work on addressing the whole family through two- or multi-generation
approaches, state implementation of the Family First Prevention Services Act, increased interest in social
emotional learning and trauma informed schools, and efforts to help families impacted by the opioid crisis.
A number of factors contributed to Tennessee’s three branches and stakeholder investment on ACEs. Strong
leaders at every level embedded the mission of BSBTN in public remarks, policy discussions, and in their
communities. The public/private relationship that serves as the foundation for BSBTN’s structure has assured
local solutions are developed to solve specific community issues. Extensive use of research-tested terminology
and methods of communication permitted common understanding of mission and expectations for culture
change. Financial investments from foundations, state appropriations, and in-kind and programmatic support
were essential. Further, the state developed approaches to assure sustainability both with and without dedicated
fiscal resources through policy and collaborations, among other strategies.
The COVID-19 pandemic may be increasing ACEs and trauma and demonstrates the importance of responding
to them at the state level. It is important to address conditions that contribute to stress and trauma including
racism, poverty, and bullying, which were not included in the original set of conditions defined as ACEs but have
since been validated as expanded ACEs. State leaders should not lose sight of the fact that experiences of
trauma are pervasive in society, yet it is critical to focus on strategies to build individual and collective resilience
and resilient communities.
A Case Study of Building Strong Brains Tennessee: An Initiative to Address Adverse Childhood Experiences and Become a Trauma-Informed State 7REFERENCES
1 Center on the Developing Child, Harvard University. ACEs and Toxic Stress: Frequently Asked Questions.
https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/
2 Felitti, V., Anda, R., Nordenberg, D., et al. (1998). Relationship of Childhood Abuse and Household Dysfunction
to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine. (14:4). DOI:
https://doi.org/10.1016/S0749-3797(98)00017-8
3 Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACEs): Preventing early trauma to improve
adult health. https://www.cdc.gov/vitalsigns/aces/index.html#:~:text=1%20in%206%20adults%20experienced,by%20
as%20much%20as%2044%25.
4 Kennedy, R. (2018). Building Strong Brains Tennessee. Tennessee Commission on Children and Youth.
https://www.tn.gov/content/dam/tn/tccy/documents/pres/pres-cad-rk-18.pdf
AUTHORS
This publication was developed by Lauren Block and Sweta Haldar at the National Governors Association Center for Best
Practices (NGA Center), in partnership with Mary Rolando, formerly with Building Strong Brains Tennessee, and Elaine Chhean
and Hemi Tewarson at the Duke-Margolis Center for Health Policy (Duke-Margolis).
ACKNOWLEDGEMENTS
NGA Center and Duke-Margolis thanks the current and former officials from Tennessee for allowing us to highlight their work
in this publication. NGA Center and Duke-Margolis also thanks the Robert Wood Johnson Foundation for its generous support
of this publication and the project that made it possible.
RECOMMENDED CITATION FORMAT
Rolando, M., Block, L., Chhean, E., Haldar, S., Tewarson, H. (2021, March). A Case Study of Building Strong Brains Tennessee:
An Initiative to Address Adverse Childhood Experiences and Become a Trauma-Informed State. Washington, DC: National
Governors Association Center for Best Practices and Duke-Margolis Center for Health Policy.
National Governors Association | 444 N. Capitol Street NW, Suite 267 | Washington, DC 20001 | 202-624-5300 | www.nga.orgYou can also read
